Institute for Healthcare Improvement (IHI)

Author in the Room: Discontinued Use of Estrogen Plus Progestin

August 2005 Author in the Room^® Teleconference

 

Authors: Judith Ockene, PhD, MEd, and David H. Barad, MD, MS

 

Article: "Symptom Experience After Discontinuing Use of Estrogen Plus Progestin"

 

Summary Points:

• Of the women who stopped estrogen plus progestin (E+P), 21.2 percent had menopausal symptoms (hot flashes or night sweats) after stopping study medication compared to 4.8 percent of women who were on placebo.
• Of the women who had menopausal symptoms when they started the study (about 12 percent) and were in the active hormone group, over 50 percent had a recurrence of symptoms after they stopped MHT compared to 21 percent of placebo users who had a recurrence of symptoms.
• Women in the E+P group reported higher rates of pain or stiffness (36.8 percent) after they stopped study medication compared to women who had been on placebo (22.2 percent).
• Women who had symptoms after they stopped study medication reported using a wide range of strategies to manage symptoms and a large proportion found the strategies to be helpful.

Author in the Room: Varicella Vaccination

September 2005 Author in the Room® Teleconference

 

Authors: Rafael Harpaz, MD, MPH, and Fangjun Zhou, PhD

 

Article: "Impact of Varicella Vaccination on Health Care Utilization"

 

Summary Points:

• Varicella can be severe and at times life threatening, however, since the introduction of varicella vaccine in 1995, varicella hospitalizations have declined significantly, as have outpatient visits.
• Herd immunity is protecting unvaccinated persons from varicella. Since varicella can be more severe in adults, it is particularly important that patients are screened for evidence of immunity to varicella and anyone susceptible is vaccinated, so that children and adolescents do not remain susceptible at adulthood. The federal government's Advisory Committee on Immunization Practices (ACIP) provides new recommendations regarding screening patients for evidence of immunity to varicella and vaccinating those at risk of the disease.
• The diagnosis of varicella has become challenging as rates have declined and since the disease is highly modified among those vaccinated. Laboratory testing will play an increasing role in diagnosis of varicella.
• Providers should report varicella to the local health department so that public health authorities can act to control outbreaks and can monitor for development of problems in the vaccination program

 

During the Author in the Room teleconference, Dr. Harpaz mentioned that the Centers for Disease Control (CDC) has some photo images of more attenuated forms of varicella.

 

Additionally, the featured authors of "Impact of Varicella Vaccination on Health Care Utilization" are happy to be emailed with any follow-up questions. Dr. Rafael Harpaz can be reached at rzh6@cdc.gov, Dr. Fanjun Zhou can be reached at FAZ1@cdc.gov.

Author in the Room: Laryngopharyngeal Reflux

October 2005 Author in the Room^® Teleconference

 

Author: Charles N. Ford, MD

 

Article: "Evaluation and Management of Laryngopharyngeal Reflux"

 

Summary Points:

• Differentiating between gastroesophageal reflux and laryngopharyngeal reflux
• Making and confirming laryngopharyngeal reflux diagnosis
• Resolution of laryngopharyngeal reflux findings may require aggressive and prolonged treatment

Author in the Room: Bariatric Surgery Mortality Among Medicare Patients

November 2005 Author in the Room^® Teleconference 

 

Author: David R. Flum, MD

 

Article: "Early Mortality Among Medicare Beneficiaries Undergoing Bariatric Surgical Procedures" 

Summary Points:

• Patients 65 years or older have a much higher risk of early death than younger patients after bariatric (obesity) surgery.
• Already a high-risk population, Medicare medically disabled patients have a higher risk of early death after bariatric (obesity) surgery is performed than previously reported.
• Older patients of more experienced bariatric surgeons had a much lower risk of death than those older patients whose surgeons had less experience performing the surgery.

Author in the Room: Antimicrobial Prescribing

December 2005 Author in the Room^® Teleconference

 

Author: Matthew H. Samore, MD

 

Article: "Clinical Decision Support and Appropriateness of Antimicrobial Prescribing" 

Summary Points:

• Repetitive use of a diagnostic and treatment algorithm to ingrain new prescribing habits was a valuable part of this practice change intervention.
• Clinical decision support systems (CDSS) are feasibly implemented in practice settings that lack electronic medical records, including rural communities.
• CDSS needs to be integrated with tools that save clinicians' time to be sustainable

Author in the Room: Gastric Acid-Suppressive Agents and C. difficile Risk

January 2006 Author in the Room^® Teleconference

 

Author: Sandra Dial, MD, MSc

 

Article: "Use of Gastric Acid-Suppressive Agents and the Risk of Community-Acquired Clostridium difficile-Associated Disease"

Summary Points:

• Acid suppressive therapy use was associated with an increased risk of community-acquired Clostridium difficile-associated disease (CDAD), with PPIs appearing to be associated with a higher risk than H2 blockers. These agents, particularly PPIs, are being prescribed with increasing frequency to patients, including situations where the benefits may be small.
• Although the rate is lower than in the hospital, CDAD is occurring in the community and is being diagnosed more frequently. 
• Prior antibiotic exposure appears to be less frequent in patients diagnosed in the community as compared to patients diagnosed in hospital.

Author in the Room: Inguinal Hernia in Minimally Symptomatic Men

February 2006 Author in the Room^® Teleconference

 

Author: Olga Jonasson, MD

 

Article: "Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men"

Summary Points:

• Men, and men only, who have few if any symptoms from their inguinal hemia can safely delay having it fixed.
• When symptoms develop, especially if the symptoms worsen suddenly, they should visit a surgeon and request a repair.
• If the hernia suddenly becomes incarcerated, painful, and signs of a bowel obstruction develop (vomiting, abdominal cramps), an operation should be done immediately. In 2006, even this emergency operation is safe and mortality rates are low.

Author in the Room: Treatment of Pain in Preterm Neonates Undergoing Central Line Placement

March 2006 Author in the Room^® Teleconference

 

Author: Anna Taddio, PhD

 

Article: "Intravenous Morphine and Topical Tetracaine for Treatment of Pain in Preterm Neonates Undergoing Central Line Placement"

Summary Points:

• Infants feel pain during central line placement and this pain can be reduced with analgesics.
• IV morphine used alone or in combination with Tetracaine Gel is more effective than Tetracaine alone or no treatment.
• IV morphine and Tetracaine Gel are associated with expected side effects; IV morphine causes mild respiratory depression and Tetracaine causes reddening discoloration of the skin. 

Author in the Room: All-or-None Measurement

April 2006 Author in the Room^® Teleconference

 

Authors: Donald Berwick, MD, MPP, FRCP, and Thomas Nolan, PhD

 

Article: "All-or-None Measurement Raises the Bar on Performance"

Summary Points:

• All-or-none measurement more closely reflects the interests and likely desires of patients than other approaches to measurement such as composite or item-by-item.
• All-or-none measurement forces a system perspective.
• All-or-none measurement offers a more sensitive scale for assessing improvements

Author in the Room: Screening Colonoscopy for Older Females

May 2006 Author in the Room^® Teleconference

 

Author: William Taylor, MD

 

Article:  "A 71-Year-Old Woman Contemplating a Screening Colonoscopy"  

Summary Points:

• Embedded in experts’ recommendations for colorectal cancer screening are nearly impossible demands on primary care clinicians to discuss the pros and cons of various modalities for screening with each patient and to assess risk even to the detail of learning the pathology of the biopsy of relatives’ colonoscopies (e.g., adenomatous vs. hyperplastic polyps).
• The complex set of components involved in the decision to screen (or not) for colon cancer includes input from both the doctor (e.g., data about what might happen and how likely the possibilities are) and the patient (e.g., how the patient weighs the relative desirability of the various possible outcomes that result from the possible decisions).
• The decision to undertake a preventive maneuver involves weighing the risks, cost, and inconvenience of an intervention now for a potential benefit in the future.